GW1-2021-07526_Well Construction - GW1_20210903

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Raymond Brown 14.WATER ZONES
FROM TO DESCRIMON
Well Contractor Name
150 ft• 160 ft.
2313
ft. ft. f
NC Well Contractor Certification Number 15.OUTER CASING for multitased wells Olt LINER tf a licable
Raymond Brown well Company, Inc FROM TO I DIAMETER I THICKNESS MATERIAL
0 ft. 44 ft. 6.1/4 in. ,M\1 t.
Company Name ,t
4440wei n20 16:INNER CASING OR TUBING eothermal closed-loo
2.Well Construction Permit#: FROM To DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIG County,State,Variance,etc) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural �Municipa]/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. it. in.
IndustriaVCommcrcial Residential Water Supply(shared) IS.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 fL 20 ft' bent8nite pour
Monitoring _'Recovery ft. ft.
Injection Well: ft. ft.
Aquifer Recharge Groundwater Remediation
79.SAND/GRAVEL PACK if appiicable
Aquifer Storage and Recovery 0Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stotmwater Drainage
ft. ft.
Experimental Technology 0Subsidence Control
Geothermal(Closed Loop) Tracer -20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) 00ther(ex lain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soilfrock type,grain size,' etc.
0 ft. 20 ft. soil
4.Date Well(s)Completed: 12/7/2020 Well ID# 20 ft. 39 ft. softandrock
5a.Well Location: 78 ft. 185 ft. bluegranite
Matthew Buckmaster ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft. tl
2612 Cliffview Dr. ft. ft. a7 Sg��g
Physical Address,City,and Zip
Alamance 21.REMARKS (\
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one]at/long is sufficient) 22.Certification:
N W `V . C . �� 12/21/2020
6.Is(are)the well(s)�II Permanent or [31remporary Signa re of Certified Well Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: E3Yes or E)No with 15A NCAC 02C.0100 or 15A NCAC 01C.0200 Well Construction Standards and that a
If this is a repair,fill out known well conslruction information and explain the nature of the copy of this record has been provided to the well owner.
repair under#21 remarks section or on the back of this form.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 185 (ft•) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifjerent(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing: 39 Division of Water Resources,Information Processing Unit,
(water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
above, also submit one copy of;this form within 30 days of completion of well
12.Well construction method: construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 15 Method of test: Sight 24c.For Water Supply&Iniection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Hth Amount: a completion of well constructions to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016